Background

Risky sexual behaviors (RSB) are becoming an important problem all over the world. RSB are defined as behaviors leading to sexually transmitted diseases and unintended pregnancies. The objective of this study was to determine the prevalence and associated factors of RSB among undergraduate students in state universities of Western Province in Sri Lanka.

Methods

A descriptive cross sectional study was conducted on1575 second and third year undergraduates using stratified cluster sampling of the selected universities. A pretested self-administered questionnaire was used to assess socio-demographic, knowledge attitudes and behavior on reproductive health. RSB was defined as reporting of one or more following behavior/s; having more than one sexual partner, use of alcohol or inability to use condom or other contraceptive methods in sexual activities. The results were expressed as prevalence and its 95% confidence interval (CI) of RSB. Multiple logistic regression was performed ascertain the association between RSB and possible associated factors. The results were expressed as adjusted odds ratios (AOR).

Risky sexual behaviors (RSB) are defined as behaviors leading to sexually transmitted diseases and unintended pregnancies. Currently about 100,000 undergraduate students studying at state universities in Sri Lanka who may be at risk of practicing RSB. This study seeks to determine the prevalence of such behaviors among this group of students.

Data were collected from second and third year undergraduate students with a questionnaire on sexual behaviors, other risk behaviors, knowledge and attitudes on sexual and reproductive health. Of students surveyed 12.4% were found to practice RSB within the last 1 year period. Several other behaviors such as alcohol consumption within the last 3 months, attending night clubs in last month and those with good knowledge on condoms were associated with RSB. Those who thought religion was very important to their lives were less likely to practice RSB. Suggestions were made to take necessary steps to minimize alcohol consumption within university and outside, to discourage night clubs attendance by facilitating more recreational activities and to promote religious activities.

Risky sexual behaviors (RSB) are becoming an important problem all over the world. The Centers for Disease Control and Prevention (CDC) defines RSB as Sexual behaviors leading to unintended pregnancies and sexually transmitted infections (STI) include Human immuno-deficiency Virus (HIV) and acquired immuno-deficiency syndrome (AIDS) [1]. It includes having multiple sexual partners, having sex without using a condom or other contraceptive method. In addition to that, several authors have included the following factors in to their definition of RSB: initiation of first sex at early age before 18 years [2, 3], sexual activity done under the influence of alcohol and anal intercourse [4], sexual violence and transactional sex [3] and paid sex [5].

There is limited literature on sexual practices among various population groups in Sri Lanka. The prevalence of risk behavior among adolescents and young adults was higher than the expected level by parents and teachers [6–8]. Global prevalence studies including other Asian countries would give a better estimate of considerably higher RSB in undergraduates [9, 10]. There is a vast amount of literature on undergraduates’ RSB in African countries indicating that higher prevalence of RSB among them ranging from 7 to 47% [11–17].

Known socio-demographic and economic risk factors associated with RSB are male sex [11, 12, 18], smoking [8, 20], night club attendance [11] and alcohol use [8, 9, 19–21]. In contrast, having a good relationship with friends, peers and parents [9], as well as religiosity [12, 22] have been found to be a protective measure against RSB.

There are more than 105,000 youths studying in universities in Sri Lanka where the majority are not in a relationship [23]. University life is a shift towards greater freedom from family and school backgrounds for most of them. It provides an opportunity to practice new friendships, social mixing and consequently to engage in risky behaviors including RSB [9]. The findings of this study could potentially support to develop programs to reduce RSB and to improve the knowledge and practices via the existing system of tertiary education. Therefore we conducted this study to determine the prevalence and factors associated with RSB among undergraduates in the state universities of the Western Province in Sri Lanka.

Study design

An institution-based descriptive cross-sectional study was conducted in four state universities in the Western Province of Sri Lanka (Univeristy of Colombo, University of Sri Jayewardenepura, University of Kelaniya and University of Moratuwa), representing around 17% of total undergraduates enrolled in state universities in the country.

Study population

The study population was undergraduate students studying in second and third years which were 18,280 in number [23]. Undergraduates from foreign countries and clergymen undergraduates were excluded. First year students were excluded as they are new to the environment. So their risk behaviors may not be due to as the same factors as second and third year students. Fourth and fifth year students were excluded as these advanced years are not conducted in every course. Exclusion of foreign students was done due to their different socio-cultural background.

Sample size and sampling technique

Calculated sample size was 1314 with expected prevalence of 13% of heterosexual intercourse without condoms among unmarried, out of school adolescents [7], 1.96 Z value, 3% of precision and a correction for design effect of 2.45 [24, 25] and 10% of non-respondents.

A multistage cluster sampling technique with probability proportional to size (PPS) was used to select a representative sample of undergraduates (Fig. 1). A cluster was defined as a tutorial group or a whole batch according to the structure of the selected undergraduates group. The average cluster size was considered as 30. Then we allocated the clusters for each academic year and university according to the proportion of undergraduates. Undergraduates were stratified according to their respective university and academic years and academic streams. Finally clusters were identified within each stratum based on PPS according to the number of students in each university and academic year.

Fig. 1

Schematic presentation of sampling technique

Data collection

Data were collected on socio-demographic factors, other risk behaviors including consumption of alcohol, smoking and using narcotic drugs, sexual behavior and knowledge and attitudes in selected aspects of reproductive health (RH) among undergraduates. Sri Lanka Behavioral Surveillance Survey questionnaire [26], Youth risk behavior surveillance questionnaire used by CDC [1] and Illustrative Questionnaire for Interview Surveys with Young People [27] were used as guides to develop the questionnaire.

The validity of the questionnaire was ensured by assessing the judgmental validity which included face, content and consensual validity. Validity was determined by assessing the agreement of the experts on whether or not the conceptual definition has been used appropriately in the tool. A multi-disciplinary panel of experts in the fields of public health, reproductive health and language was used for assessment of validity. The questionnaire was forward-translated into Sinhala and back-translated to English. Data were collected using a pre-tested self-administrative questionnaire after obtaining permission. The filled questionnaires in an envelope were collected by trained research assistant. The data collection procedure was supervised by the first author. Informed written consent was obtained from the participants. Ethical clearance was taken from the Ethical Review Committee, Faculty of Medicine, University of Kelaniya.

Knowledge on some aspects of RH was measured with statements on unsafe abortions, contraceptives including condoms, STIs including HIV/AIDS and sexual and RH rights. Attitudes on RH was measured with statements on contraceptives, condoms and HIV/AIDS which contained five responses; strongly agree, agree, neutral, disagree and strongly disagree.

RSB was defined as reporting one or more following behavior/s; having more than one sexual partner, alcohol use with sexual activities, inability to use condom to prevent STI in sexual activities with commercial sex workers or non-commercial partners, unable to use contraceptive methods to prevent unintended pregnancy in sexual activities with commercial sex workers or non-commercial partners. RSB was defined as for the last 1 year and the last 3 months separately.

Data analysis

Data were analyzed with Statistical Package for Social Science (SPSS) (Version 16). Prevalence and 95% confidence interval (CI) of RSB were calculated for last 1 year and last 3 months periods separately. Sex specific RSB and university specific RSB was calculated for last 3 months period. To ascertain the association between RSB and other variables binary logistic regression was performed. Variables with p value less than or equal to 0.20 at binary were entered into multiple logistic regression analysis. Hosmer Lemshow goodness of fit with backward elimination was used to test for model fitness. Variables with p value of < 0.05 at multiple regression were considered as statistically significant. The results were expressed as Odds Ratio (OR) and adjusted odds ratios (AOR).

Background information

The study sample consisted of 1575 undergraduates from four state universities in the Western Province. Majority of respondents were females (n = 926, 58.8%) and unmarried (98.5%, n = 1551). Mean age was 23 (SD = 0.9) years. The sample consisted more Sinhalese (94.1%, n = 1480) than non-Sinhalese and Buddhists (89.8%, n = 1414) than non-Buddhists. Socio-demographic factors are shown in Table 1.

Table 1

Socio-demographic characteristics among the undergraduates

Characteristics

Frequency

Percentage

Sex

Male

645

41.0

Female

926

58.8

Age (in years)

21

20

1.3

22

449

28.5

23

696

44.2

24

307

19.5

25

83

5.3

26

11

0.7

Academic year

Second

930

59.0

Third

645

41.0

University

Kelaniya

339

21.5

Sri Jayewardenepura

576

36.6

Colombo

353

22.4

Moratuwa

307

19.5

Nationality

Sinhalese

1480

94.1

Tamil

58

3.7

Muslims

33

2.1

Other

1

0.1

Religion

Buddhism

1414

89.8

Roman Catholic

65

4.1

Non Roman Catholic Christian

6

0.4

Islam

45

2.9

Hindu

39

2.5

Other

3

0.2

Residence

Own home

453

28.8

Relative’s house

36

2.3

University hostel

411

26.1

Boarding place

671

42.6

Academic streams

Art

516

32.8

Commerce

424

26.9

Bio Science

248

15.7

Mathematics

387

24.6

Type of School

Boys’

262

21.0

Girls’

345

27.6

Mixed

642

51.4

Marital status

Single

1551

98.5

Married

13

0.8

Divorced

1

0.1

Separated

1

0.1

Living together

5

0.3

The prevalence of RSB

The prevalence of RSB among undergraduates were 12.4% (n = 196;, 95% CI: 11.8–13.1) and 12.1% (n = 190, 95% CI: 11.5–12.7) for last 1 year and last 3 months respectively. The highest percentage (16.8%, n = 57) of undergraduates with RSB was in University of Kelaniya followed by University of Sri Jayewardenepura (12.5%, n = 72). Males (19.1, 95% CI 16.1–22.2) had more RSB than females (7.2, 95% CI 5.5–8.9) (p < 0.001).

Sexual behavior of the participants

In the study sample 21.2% (n = 334) reported ever having had sexual exposure. Males (32.7%, n = 211) had more ever sexual exposure than females (13.1%, n = 122) (p < 0.001). Majority of undergraduates (63.9%, n = 205) who ever had sexual exposure experienced their first intercourse after 20 years of age. More females (75%, n = 87) than males (57.8%, n = 118) had their first sexual exposure before the age of 20 years (p = 0.002). Out of 334 undergraduates had sexual exposure ever, 3.3% (n = 11) stated that their first sexual experience was a forced sex. Majority (75.4%, n = 252) of the respondent’s first sexual partner was a girl/boyfriend.

Out of 334 with had ever sexual exposure only 18% (n = 60) of the respondents had used condoms in first sexual intercourse while only 1.5% (n = 5) of the respondents had used alcohol in first sexual intercourse. Out of all undergraduates, 13.7% (n = 216) had more than one life time sexual partners.

Percentage of undergraduates who had sexual intercourse within last 1 year was 87.7% (n = 293) out of 334 respondents who ever had sex. Majority of them had one sexual partner irrespective of whether they have engaged in sexual intercourse in last 1 year or last 3 months. Ninety four (5.96%) and 79 (5.01%) respondents had multiple sexual partners within last 1 year and 3 months respectively. The majority (85.8%, n = 176) of undergraduates those who had sexual intercourse within last 1 year had not used condoms in their last sexual activity. Out of 17 undergraduates that had sexual intercourse with commercial sex worker, 58.8% (n = 10) had used condom at their last sexual activity. The percentage used condoms at last sex with non-commercial sex partners were 12.4% (n = 24).

Factors associated with RSB in bivariate analysis

Being a male undergraduate and belonging to Sinhala ethnicity showed significant association with RSB in bivariate analysis. As shown in Table 2, RSB for last 3 months was negatively associated with engaging more religious activities and considering religion as more important to their lives. Having to the opportunity to talk with parents and siblings regarding sexual problems showed negative association with RSB.

Table 2

Unadjusted odds ratios for association of risky sexual behavior with socio-demographic, social and economic factors

Factors

Risky sexual behavior

OR

p value

Yes No (%)

No No (%)

(95%CI)

Sex

Male

123 (64.7)

522 (37.8)

3.02 (2.20–4.15)

< 0.001

Female

67 (35.3)

859 (62.2)

Reference

Age

≤ 22 yrs

55 (29.3)

414 (30.0)

1.04 (0.74–1.45)

0.83

> 23 yrs

133 (70.7)

964 (70.0)

Ref

Residence

Outside home

137 (72.1)

948 (68.5)

1.19 (0.85–1.66)

0.31

In home

53 (27.9)

436 (31.5)

Ref

Religion

Buddhist

176 (92.6)

1238 (89.4)

1.50 (0.84–2.64)

0.17

Non-Buddhists

14 (7.4)

147(10.6)

Ref

Ethnicity

Sinhala

188 (98.9)

1292 (93.3)

6.77 (1.65–27.69)

0.002

Non- Sinhala

2 (1.1)

93 (6.7)

Ref

Income

≤ 50,000 rupees

139 (77.2)

1055 (82.8)

0.70 (0.48–1.03)

0.07

> 50,000 rupees

41 (15.8)

219 (17.2)

Ref

Financial support

> 3000 Rs/month

13 (9.8)

81(7.8)

1.28 (0.69–2.37)

0.43

≤ 3000 Rs/month

119(90.2)

951 (92.2)

Ref

Academic year

Second

112 (58.9)

818 (59.1)

1.005(0.74–.37)

0.98

Third

78 (41.1)

567 (40.9)

Ref

Academic stream

Bio-Science

26 (13.7)

222 (16.0)

0.83 (0.54–1.29)

0.41

Non Bio-Science

164 (86.3)

1163 (84.0)

Ref

School type

Mixed

70 (49.0)

575 (51.8)

0.89 (0.63–1.26)

0.51

Non-mixed

73 (51.0)

534 (48.2)

Ref

Religious activities

More

58 (30.5)

615 (44.8)

0.54 (0.39–0.75)

< 0.001

Less

132 (69.5)

759 (55.2)

Ref

Importance of religion

More

118 (62.1)

1084 (78.3)

0.46 (0.33–0.63)

< 0.001

Less

72 (37.9)

301 (21.7)

Ref

Access to talk with relative,

Yes

110 (57.9)

969 (70.1)

0.59 (0.43–0.80)

0.001

No

80 (42.1)

416 (30.0)

Ref

Access to talk with friends

Yes

177 (93.2)

1231 (88.9)

1.70 (0.95–3.06)

0.07

No

13 (6.8)

154 (11.1)

Ref

Further, RSB were significantly associated with undergraduates who attended nightclubs more than once within last month, those who had used internet facilities > 2 h per day, those who went to cinema ≥2 per months, who had taken alcohol within last 3 months, who had smoked within last 3 months, who had taken ganja (cannabis) within last 3 months and who had physical fight within last 1 year in university (Table 3).

Table 3

Unadjusted odds ratio for association of risky sexual behaviors with other risk behaviors

Other risk behavior

Risky sexual behavior

OR

p value

Yes No (%)

No No (%)

(95%CI)

Attend night clubs in last month

≥ once /month

9 (4.7)

8 (0.6)

8.56 (3.26–22.46)

Not in last month

181 (95.3)

1377 (99.4)

Ref

< 0.001

Using Internet facilities

≥ 2 h/day

88 (46.3)

526 (38.0)

1.41(1.04–1.91)

< 1 h/day

102,953.7)

859 (62.0)

Ref

0.027

Monthly frequency of going to cinema halls

≥ 2per month

34 (17.9)

134 (9.7)

2.03 (1.35–3.07)

0.001

< 1 per month

156 (82.1)

1251(90.3)

Ref

Had taken alcohol in last three months

Yes

79 (41.6)

195 (14.1)

4.34 (3.14–6.02)

< 0.001

No

111 (58.4)

1190 (85.9)

Ref

Had smoked within last three months

Yes

33 (17.4)

76 (5.5)

3.62 (2.33–5.63)

< 0.001

No

157 (82.6)

1309 (94.5)

Ref

Had taken Marijuana within last three months

Yes

15 (7.9)

32 (2.3)

3.62 (1.92–6.83)

No

175 (92.1)

1353 (97.7)

Ref

< 0.001

Had physical fighting in last one year in university

Yes

25 (13.2)

35 (2.5)

5.84 (3.41–10.01)

No

165 (86.8)

1350 (97.5)

Ref

< 0.001

Good knowledge on contraceptives, good knowledge on condoms, good knowledge on sexual and RH rights, good overall knowledge on RH, favorable attitudes on contraceptives, favorable attitudes on condoms and favorable overall attitudes on RH showed statistically significant associations in bivariate analysis with RSB (Table 4).

Table 4

Unadjusted odds ratios for association of RSB with knowledge and attitudes on reproductive health

Knowledge and attitude aspect

Risky sexual behavior

OR

p value

Yes No (%)

No No (%)

(95%CI)

Knowledge on Unsafe abortions

Good

109 (57.4)

730 (52.7)

1.21 (0.89–1.64)

Averagea

81 (42.6)

655 (47.3)

Ref

0.227

Knowledge on Contraceptives

Good

71 (37.4)

376 (27.1)

1.60 (1.17–2.0)

Averagea

119 (62.6)

1009 (72.9)

Ref

0.003

Knowledge on Condoms

Good

145 (76.3)

597 (43.1)

4.25 (3.00–6.04)

< 0.001

Averagea

45 (23.7)

788 (56.9)

Ref

Knowledge on Sexually Transmitted Infections

Good

35,918.4)

227 (16.4)

1.15 (0.78–1.71)

0.481

Averagea

155 (81.6)

1158 (83.6)

Ref

Knowledge on HIV/AIDS

Good

125 (66.8)

851(62.0)

1.23 (0.89–1.71)

0.201

Averagea

62(33.2)

521 (38.0)

Ref

Knowledge on Sexual and Reproductive health rights

Good

58 (30.5)

327 (23.6)

1.42 (1.02–1.98)

Averagea

132 (69.5)

1058 (76.4)

Ref

0.038

Overall knowledge on Reproductive health

Good

45 (23.7)

241 (17.4)

1.47 (1.03–2.12)

0.035

Averagea

145(76.4)

1144 (82.6)

Ref

Attitude on contraceptives

Desirable

75 (39.5)

402 (29.2)

1.58 (1.15–2.16)

0.004

Undesirable

115 (60.5)

974 (70.8)

Ref

Attitude on Condoms

Desirable

121 (63.7)

487 (35.4)

3.20 (2.33–4.38)

< 0.001

Undesirable

69 (36.3)

888 (64.6)

Ref

Attitude on HIV/AIDS

Desirable

93 (49.5)

588 (42.7)

1.32 (0.97–1.78)

0.081

Undesirable

95 (50.5)

788 (57.3)

Ref

Attitude on Overall Reproductive health

Desirable

92 (48.4)

388 (38.0)

2.41 (1.77–3.28)

< 0.001

Undesirable

98 (51.6)

997 (72.0)

Ref

aSatisfactory and poor knowledge were amalgamated as average knowledge

OR, odds ratio, CI, confidence interval

Factors associated with RSB in multivariate analysis

Multiple logistic regression model included 1575 participants. RSB during the last 3 months showed significant association with four factors. Those who had taken alcohol within last 3 months (AOR 2.59, 95% CI: 1.82–3.70), those who had attended nightclub more than once in last month (AOR 3.61; 95% CI: 1.31–9.97), and those who had good knowledge on condoms (AOR 2.91, 95% CI: 2.00–4.24), showed positive association with RSB. Those who considered the religion to be important to their lives (AOR 0.67, 95% CI: 0.48–0.95), showed negative association with RSB. (Table 5) Reanalysis of data excluding the variable ‘use of alcohol within last three months’ had not changed the results.

Table 5

Adjusted odds ratios for Risky Sexual Behavior among undergraduates within last three months

In this study an attempt has been made to assess the prevalence of RSB and factors associated to RSB among undergraduate students in state universities of Western Province in Sri Lanka.

Prevalence of RSB

The prevalence of RSB was 12.4 and 12.1% for last 1 year period and for last 3 months period respectively. Prevalence among male and female undergraduates were 19.1 and 7.2% respectively. A study carried out among first year Agricultural undergraduates of University of Ruhuna, Sri Lanka reported that 2% had multiple sexual partners during last 3 months which was considered as a risk behavior [28]. In the present study, having multiple partners during last 3 months was 5% and the observed difference may be due to the difference of the sample selected i.e. second and third year representing all study streams from four universities. Another study carried out among Ethiopian undergraduates revealed that 18.6% of them had lifetime multiple sexual partners which was 13.7% in the present study [29]. Their use of condoms during first sexual intercourse was 11.2%, much lower than the present 18% figure. Their figure for not using condoms within the last 1 year period was 39.4% from those who had sex in last 1 year. In the present study, not using condoms in last sexual activity was 85.8% which was much higher. The figure may be due to the reason that our young people are having “somewhat mutually monogamous” relationships which they would think the need of condom use is unnecessary.

Factors associated with RSB

In the present study, those who had good knowledge on condoms showed a positive association with RSB. This finding was in line with a study carried out in Washington which discussed an association with knowledge on condoms and condom usage. Failure to use protective method in risk behavior may not be due to the ignorance but may be the inability of perceiving the risk [30]. Undergraduates who had experienced or are interested in sexual behaviors may be enthusiastic in finding more information on preventive measures of STI i.e. usage of condoms. Peltzer has stated that those who had recent sexual exposures had correct knowledge on condoms [31].

The present study revealed that those who considered religion is more important to their lives were less likely to be associated with RSB than those who did not. Similar comparable results were also reported among adolescent and young adults in USA [22]. In contrast to the findings, a study done among undergraduates at the University of Kentucky revealed that students with higher religious beliefs but lower religious behaviors were at risk for risky sexual practices [32].

Frequently attending nightclubs showed significant positive association with RSB in the present study. In compatible with these findings, attending night clubs showed significant association with having sex ever, having multiple sexual partners and having sex with commercial sex workers in a study from Ethiopia [33]. The difference in the degree of association may be due to the different definitions of RSB in these two studies. Difference of academic year of selected study participants may have contributed to the observed dissimilarity. The Ethiopian study had selected undergraduates from all 5 years including 1st, 4th and 5th academic years which we have excluded in the present study. Another study conducted among undergraduates had showed different degree of positive association between RSB and attending night clubs [11].

Present study showed a statistically significant positive association with alcohol consumption within the past 3 months’ time. The results were compatible with few other studies [16, 25, 34, 35]. Alcohol use together with sexual activities itself are within the definition of RSB in our study, even though none of them had taken alcohol intake as a factor in their definition of RSB. The observed association may be due to an impaired decision making ability and dis-inhibition behavior due to alcohol consumption.

Kebede et al. revealed a positive association between unprotected sex and using alcohol daily [20]. Alcohol consumption has been measured for past 3 months’ time while unprotected sex for the period of last 1 year. Undergraduates in England perceived that life style in university provided opportunities for risky sex via high level of alcohol consumption along with other factors like increased sexual opportunities [35]. As described by Cooper, drinking alcohol may have an association that could not be described easily [21]. Therefore there exists a definite need for further research, both quantitative and qualitative in order to describe relationship between alcohol consumption and RSB.

Given the cross sectional nature of the study design, it was difficult to identify cause and effect association between the variables. As the discussed topic was very sensitive and the information was self-reported, there may be possibility of deliberately hiding of information in relation to unacceptable behavior. The results could be generalized to all the universities in Western Province and all university students in Sri Lanka as participants for the study are from all over the country.

Risky sexual behavior was prevailing among undergraduates at a rate of 12.4%. Males had more RSB than females. Those who had taken alcohol within last 3 months, had attended night clubs more than once in the last month and had good knowledge on condoms were associated with higher risk of RSB Undergraduates’ consideration of the religion as more important to their lives had lower risk with RSB.

Authorities of university and health care providers should consider the need and take necessary actions to establish accessible, affordable RH services within university. They should consider taking necessary steps to minimize alcohol consumption within university and outside society. Authorities within university and outside should discourage night clubs attendance among undergraduates by encouraging more recreational activities with the help of peer leaders, academic and non-academic staff members and other organizations. Religious activities should be promoted within universities and outside.

Acknowledgements

All the undergraduates who participated for the study and the staff of the Universities, data collectors and the members of the Board of Study in Community Medicine, Postgraduate Institution of Medicine.

Funding

The Medical Research Institute of the Ministry of Health, Sri Lanka funded for the data collection of the study.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

Both authors have contributed equally to the design the study. UP and CA analyzed and interpreted the data. UP was responsible for the conduct of the literature review and implementation of study and a major contributor in writing the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Administrative clearance was obtained from the Vice Chancellors and Deans of the selected faculties. Informed written consent was obtained from the participants. Ethical clearance was taken from the Ethical Review Committee, Faculty of Medicine, University of Kelaniya.

We allowed participants to complete the questionnaire on their own in privacy, seated with an adequate distance from others. An envelope was given to each participant to hand over the filled questionnaire without others’ interferences.

Competing interests

The authors declare that they have no competing interests.

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